TNCO FY2023 Membership Application

Application

Membership in the Tennessee Community Organizations is tax deductible; however, federal tax regulations require that TNCO disclose the percentage that is deductible in lieu of lobbying expenses. TNCO estimates that 70 percent of your dues may be tax deductible for the FY2023 fiscal year.

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* 1. Agency Information. By providing this information to Tennessee Community Organizations (TNCO), I consent to receive communications, including but not limited to newsletters, announcements, registration forms, program promotions, advertisements for goods and services, sent by TNCO via regular mail, email, texts, telephone or fax.

Your Name *

Agency Name *

Address *

Address 2

City/State *

ZIP *

E-mail Address *

Phone *

CEO/Executive Director Name *

CEO/Executive Director E-mail Address *

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* 2. Is your agency accredited?

Yes

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* 3. If you answered yes to question 2 then by which entity are you accredited?

CARF (Commission on Accreditation of Rehabilitation Facilities)

COA (Council on Accreditation)

CQL (Council on Quality and Leadership)

The Joint Commission

Other (please specify)

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* 4. If you answered no to question 2, does your agency plan to become accredited?

Yes

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* 5. If you answered yes to question 4 then from which entity will you be seeking accreditation?

CARF (Commission on Accreditation of Rehabilitation Facilities)

COA (Council on Accreditation)

CQL (Council on Quality and Leadership)

The Joint Commission

Other (please specify)

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* 6. What year was your agency founded/established?

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* 7. In what region or regions of Tennessee does your agency provide services?

West

Middle

East

Statewide

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* 8. In what counties do you provide services?

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* 9. Total # of people your agency serves/ supports?

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* 10. How many people does your agency employ?

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* 11. Please list who is designated as the primary and the alternate to vote for your agency. Each agency, according to TNCO’s bylaws, can cast only one vote from either the primary or alternate designee. The bylaws also state that only the primary or the alternate designee may serve on the Board of Directors.

Primary

Alternate

DUES CALCULATION is based on your agency’s FY2020-2021 actual, audited service revenue. This DOES include revenues derived for the provision of ANY state or waiver-funded service including managed care organizations, TennCare, DIDD and ICFs/IDD revenue. DO NOT INCLUDE COVID RELIEF Funds or revenue from fundraising, supported living start-up funds, food stamps, STRAP, SSI or other client generated revenue, the sale of assets, capital or other grants, United Way, county or city appropriations, tax refunds or other non-service related revenue.

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* 12. What is your audited FY2020-2021 service revenue?

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* 13. Find your audited FY2020-2021 revenue in TNCO's Dues Chart (see chart below) and enter the corresponding FY2023 dues rate. This is your agency's total dues for this fiscal year.

Your Annual Dues & Total Owed

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TNCO FY2023 Annual Membership Dues

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* 14. How will you pay your dues (TNCO will invoice you)?

One payment (full dues)

Quarterly payments

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* 15. Now's a great time to volunteer for one or more of TNCO's Committees. Select as many as you like.

Accreditation

Governmental Affairs

Health Care

Membership

Public Relations

Regulatory

Technology

TEIS

Vocational Rehabilitation